Authorization to Consent to Treatment for Minor Children
St. Joseph’s Hospital 611 St. Joseph’s Ave. Marshfield, WI 54449 (715) 387-7676 Parents: This form gives St. Joseph’s hospital permission to treat your child in the event of an emergency. This must be filled out and signed by a parent/guardian even if the child is 18 years or older. Please have your child return this to his/her director. The director will turn this in at the registration table on the day of the festival. The undersigned parent/guardian of the above named child, in the event that he/she cannot be contacted through reasonable efforts, does hereby empower and grant St. Joseph’s Hospital permission to consent to and authorize medical treatment and hospital care for my above named child. This authorization shall be valid for the _____ day of _______________, 20____. I do hereby indemnify and hold harmless the physicians, hospital and other persons who act in reliance upon this authorization. ____________________________________ Signature of Parent/Guardian __________________ Date ____________________________________ Student’s Name ____________________________________ High School
________________________________________________________________________ Phone Number(s) where you can be reached at work or at home. ________________________________________________________________________ Allergies of Child ________________________________________________________________________ Medications child is taking. ________________________________________________________________________ Date of last tetanus (DPT, lockjaw) shot ____________________________________ Name of family doctor ________________________ Doctor’s phone #
________________________________________________________________________ Name of your health insurance carrier, ID number and group number